Restless Legs Syndrome (RLS)

What is Restless Legs Syndrome?

Restless legs syndrome (RLS), also called Willis-Ekbom disease, is a common, chronic movement disorder in which a person has an irresistible urge to move the legs, usually with abnormal non-painful sensations that start at rest and improve with activity.^[1] About 3% of US adults have clinically significant RLS, and it can seriously disturb sleep.^[2]

Common symptoms

The key features are an urge to move the legs, sensations that begin or worsen at rest, relief with movement, and symptoms that are worse in the evening or at night.^{[1, 2]}

• Achy, tingling or crawling feelings in the legs, sometimes in the arms
• Trouble falling asleep, staying asleep or returning to sleep
• Leg jerks during sleep, known as periodic leg movements of sleep^[1]
• Daytime tiredness, low mood and reduced quality of life^[2]

Causes and risk factors

The cause is not fully understood. Brain iron deficiency and changes in dopamine, adenosine and glutamate signaling are being studied, and genetics, environment and other conditions all contribute.^[3] RLS is more common in iron deficiency anemia, kidney failure, pregnancy, peripheral neuropathy, Parkinson disease and multiple sclerosis, and in women and older adults.^[2]

Some medicines can make RLS worse, including serotonergic antidepressants, dopamine-blocking drugs and sedating antihistamines, as can alcohol, caffeine and untreated sleep apnea.^{[2, 4]}

How it is diagnosed and treated conventionally

RLS is diagnosed from the history, and a sleep study is not recommended for diagnosis.^[2] Doctors check iron stores, including ferritin and transferrin saturation, and look for other causes.^[4]

The first steps are to address triggers and replace iron when it is low. Gabapentinoids are now first-line medicines. Dopamine agonists are no longer first-line because they can cause augmentation, a worsening of symptoms.^{[2, 4]} Opioids and other medicines are used when first-line treatment fails.^[2]

Why Restless Legs Syndrome calls for a whole-person approach

RLS is linked to iron status, brain signaling, sleep, mood and other illnesses all at once.^{[2, 3]} No single treatment addresses every one of these.

Supportive care can help with comfort, relaxation and sleep, but it should follow a medical check for iron deficiency and other causes.

Iron status

Brain iron deficiency is one of the leading ideas about how RLS arises, and guidelines say iron levels should be tested in everyone with clinically significant RLS.^{[3, 4]} Iron should be taken only after testing and under medical supervision, because the thresholds for treatment are specific.^[4]

Nerve signaling and movement

Dysfunction of dopamine and nerve-pain pathways is suspected, though the pathophysiology is still unclear.^{[3, 5]} Movement-based measures, including exercise and some physical devices, have shown benefit for symptoms in the trials reviewed, though few studies were found and quality was not high.^{[6, 7]}

Sleep and mood

RLS often disrupts sleep. People with RLS have higher rates of depression, reported at about 30 percent in one review, and an increased rate of suicidal thoughts.^[2] Treating sleep and mood is part of care.

Medicines and other health conditions

Medicines, caffeine, alcohol, sleep apnea, pregnancy and kidney disease can each change RLS, so their review is a standard first step.^{[2, 4]}

Acupuncture for Restless Legs Syndrome

What the research shows

Acupuncture may help some people with RLS, but the evidence is limited and of low quality. A Cochrane review found only two eligible trials with 170 patients and concluded that there was insufficient evidence to know whether acupuncture is effective or safe.^[8]

A later meta-analysis of 18 studies, mostly lower quality, found improvements in RLS rating scores and higher effective rates with acupuncture alone or combined with other treatments. The authors called for well-designed trials with a sham acupuncture arm.^[9] A systematic review of 11 non-drug trials found standard acupuncture reduced RLS severity compared with control conditions and improved some sleep outcomes, but few studies were found and quality was not high.^[7] A broader review of complementary therapies likewise listed acupuncture among options that eased symptom severity in primary RLS.^[6]

In a small single-blind trial of 35 people with RLS who were on hemodialysis, 12 acupuncture sessions over 4 weeks improved RLS and insomnia scores more than control, with no adverse effects seen during dialysis.^[10] The trial was small and it is not clear that the result applies to people without kidney failure.

How acupuncture may work

How acupuncture might help RLS is not known. In the hemodialysis trial, measures of heart rate variability also changed in the acupuncture group, but whether this explains symptom relief is unknown.^[10]

What treatment involves

Treatment uses fine, sterile, single-use needles, with sessions of about 20 to 40 minutes. The hemodialysis trial used 12 sessions over 4 weeks.^[10] We reassess after a short course of visits.

In prospective studies, about 9 in 100 patients had a minor reaction such as brief bleeding, soreness or redness at a needle site, and serious events occurred in about 1 in 10,000 patients.^[11] Tell the practitioner first if you have a bleeding disorder, take blood thinners, are pregnant, or have a pacemaker or other implanted device, which matters for electroacupuncture.

Ayurvedic medicine for Restless Legs Syndrome

The Ayurvedic view

Ayurveda has no single classical condition that matches RLS. Restlessness, crawling sensations and disturbed sleep are traditionally described as a disturbance of Vata, the principle said to govern movement and the nervous system. These are traditional categories, not biomedical diagnoses.

Therapies that may be used

Care is chosen for the individual and, in tradition, may include:

• Regular sleep and meal times, and avoiding stimulants late in the day
• Warm-oil massage of the legs and feet and a warm bath in the evening
• Individually prescribed herbs

Panchakarma procedures are not appropriate during pregnancy, acute illness or frailty. They would only be considered after your physician has assessed your iron status and other causes of RLS.

What the research shows

We found no clinical trials of Ayurvedic medicine, Ayurvedic herbs or Panchakarma for RLS in PubMed, so the evidence is none. The closest studied practice is yoga, which comes from the same Indian tradition. A systematic review of non-drug treatments found that yoga improved some sleep-related outcomes in RLS, though few studies were found and quality was not high.^[7] A broader review of complementary therapies also reported that yoga improved RLS-related problems.^[6]

Herbal medicine for Restless Legs Syndrome

Herbs and formulas that have been studied

Chinese herbal formulas are the main herbal approach studied for RLS, and a review identified more than 40 formulas in the literature.^[12] One review focused on formulas containing Paeoniae Radix, peony root, which has traditionally been used for leg discomfort.^[13] Valerian and some nutrient supplements have also been tested.^[14]

What the research shows

The evidence is limited. A review of 85 Chinese herbal studies found that only nine had a control group and three were randomized, and it called for higher-quality trials.^[12] A meta-analysis of 12 trials with 639 patients found that peony root-containing formulas improved response rates, RLS scores and sleep quality compared with non-herbal treatment, though study quality was low.^[13]

Valerian did not show a statistically significant improvement in the supplement review, and the American Academy of Sleep Medicine guideline suggests against its use for RLS, based on very low certainty evidence.^{[4, 14]} In that review, magnesium and vitamin B6 improved sleep quality and RLS symptoms, but half of the studies had a high risk of bias.^[14] These are supplements, not herbs, and should be discussed with your physician first.

Safety and herb-drug interactions

Herbs can interact with medicines. Case reports describe bleeding when warfarin was combined with herbs including dan shen, dang gui, ginger and ginseng.^[15] Reviews also describe interactions between herbs and antidepressants, sedatives and other prescriptions.^[16] Since some antidepressants and antihistamines can worsen RLS, review all medicines with your prescriber.^[4]

About one fifth of Ayurvedic products bought online contained detectable lead, mercury or arsenic.^[17] Herbs should come from tested sources and be prescribed individually. Tell us if you are pregnant or breastfeeding, or have liver or kidney disease.

Translating traditional medicine into modern biological language

This is interpretation, not equivalence. Chinese medicine often describes RLS in terms of blood deficiency, liver and kidney imbalance, or stagnation in the leg channels, and peony root is traditionally used for leg discomfort.^[13] Ancient Chinese texts describe leg discomfort resembling RLS.^[12] Researchers instead study brain iron, dopamine and other signaling pathways, nerve activity and sleep regulation.^[3]

Ayurveda's aggravated Vata describes restlessness and disturbed sleep. No study has shown that a dosha corresponds to a specific biological process.

How this care fits with your medical care

Integrative care for RLS is complementary. Keep seeing your physician or sleep specialist, and do not stop or change prescribed medicines or iron treatment without your prescriber. Stopping some medicines suddenly can cause problems. We do not diagnose RLS or its cause, and new symptoms should be evaluated first.

Please bring your diagnosis, recent iron studies including ferritin, a full list of medicines and supplements, and any sleep study results.

When to seek urgent medical care

RLS itself is not an emergency, but some symptoms need prompt assessment.

• A swollen, painful, red or warm leg, or sudden chest pain or shortness of breath
• New leg weakness, numbness, or loss of bladder or bowel control
• Symptoms that spread, start earlier in the day or sharply worsen after starting a medicine, which may be augmentation and needs a call to your prescriber^[2]
• Thoughts of suicide or self-harm (call or text the 988 Suicide and Crisis Lifeline)^[2]

For a swollen leg, chest pain, shortness of breath, new weakness or loss of bladder or bowel control, or thoughts of suicide, call 911 or go to the nearest emergency department.